Provider Demographics
NPI:1811590623
Name:GROSS, VICKY JO (NP)
Entity Type:Individual
Prefix:
First Name:VICKY
Middle Name:JO
Last Name:GROSS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 CANARIS ST
Mailing Address - Street 2:
Mailing Address - City:CONSTANTINE
Mailing Address - State:MI
Mailing Address - Zip Code:49042-1016
Mailing Address - Country:US
Mailing Address - Phone:269-464-9118
Mailing Address - Fax:
Practice Address - Street 1:4600 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46619-2320
Practice Address - Country:US
Practice Address - Phone:574-282-1294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704270659363LA2200X
IN71011297A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health